What helps young people who are convinced they were born the wrong gender? What can doctors, therapists and parents do to best support these young people? A new guideline should now provide clarity on these questions.
In any case, the need for help is obvious: “We know that these children and young people have an increased risk of developing depressive illnesses, anxiety disorders, self-harming and suicidal behavior,” says Sabine Maur, psychological psychotherapist and Vice President of the Federal Chamber of Therapists. Maurer is co-author of the new guidelines for Germany, Austria and Switzerland, which were developed by experts from 27 specialist societies and two associations.
“However, we have not yet had any professionally set standards as to what such care should look like, both in terms of content and form. And that is why it is absolutely important to have such guidelines for patient protection,” says Maur.
They worked on it for seven years. Studies reviewed, discussed, weighed up. It has been available to specialist societies for comment since the beginning of the week. Because wording can still change, it is not yet publicly visible. “Most of the recommendations were made with over 95 percent consensus,” says Dagmar Pauli, deputy director of child and adolescent psychiatry and psychotherapy at the Psychiatric University Hospital in Zurich and herself the author of the S2K guidelines, whose recommendations are based on this structured form of consensus-building .
The sensitive question of puberty blockers was discussed in particular detail. The long-term safety and effectiveness of the therapy have so far been poorly investigated. Some of the experts were now available to answer questions from the German Science Media Center (SMC).
Puberty blockers are medications that were originally prescribed primarily to children whose puberty began much too early. However, for more than two decades, doctors have been able to use these medications off-label to treat adolescents whose gender identity differs from their physical sex. Experts also call this gender dysphoria. The drugs prevent the male hormone testosterone from being produced in the testicles or estrogen from being produced in the ovaries. The result: a broken voice and facial hair don’t grow, and the breasts don’t grow. In short, puberty is stopped like a pause button. In this country, whether the break makes sense is decided after careful consideration by a treatment team together with the young people and their parents.
It should “first of all make it possible to breathe a sigh of relief in this life crisis and then also to reach an understanding with therapeutic help about what exactly constitutes this crisis and how to deal with it appropriately,” says Claudia Wiesemann, director of the Institute for Ethics and History in medicine at the University Hospital of Göttingen. Basically the treatment is reversible. If young people stop the blocker treatment, they go through male or female puberty as usual.
However, if it turns out that the young people do not want to live with the physical characteristics of their biological gender, they can grow breasts or beard hair with the targeted administration of estrogen and testosterone. In fact, most people choose this route.
England’s health service, the NHS, recently stopped prescribing puberty blockers to children. For the time being, the drugs will only be distributed there as part of clinical studies. Sweden has followed a similar path. The reason for this was missing data. That’s not entirely wrong; in fact, the evidence is thin, especially when it comes to long-term progression. On the other hand, medicine has accumulated experience with these medications over decades.
The supply situation seems to be a much bigger problem. In fact, many countries lack sufficient resources to support and accompany young people. This makes detailed diagnostics, psychotherapy and social support for those affected difficult. In England, the largest British gender clinic was closed in 2022 because children there were given puberty blockers without lengthy examinations by doctors from different disciplines or information about side effects. The long waiting times alone make the supply there catastrophic, says Pauli. Young people would “sometimes wait three years for an initial appointment.”
Georg Romer, Director of the Clinic for Child and Adolescent Psychiatry at the University Hospital of Münster, recently wrote in a statement for the Deutsche Ärzteblatt: “Due to the extremely long waiting times, many patients are already 16 years old or older when treatment begins and are therefore at an age at which the benefit can be realized a puberty block can be viewed as minimal.”A later, persistently painful stigmatization can hardly be prevented once biological boys have had their voices break. So even waiting has side effects.
“If the indication for puberty blockage arises, then it is in a person who has the experience of being forced into the completely wrong gender,” says Claudia Wiesemann. In the best case scenario, he or she could make a thoughtful decision about their own future.
“To refuse this, to refuse it in principle, out of concern that this puberty block could have physical side effects, that is medically and ethically inappropriate,” said Wiesemann. Compared to the crisis situation, the side effects for those affected are generally insignificant.
Undesirable consequences of the treatment could, for example, affect the bones. There are indications that mineralization can suffer. However, it has not yet been shown whether this means that these people have a higher risk of bone fractures as adults.
“At the same time, we have very concrete evidence that people would suffer greatly if we actually forced them through this unwanted puberty,” says Achim Wüsthof, specialist in pediatric and adolescent medicine at the Hamburg Endocrinology Center. He is also one of the authors of the guideline.
In a few weeks, the S2K guidelines on gender incongruence and gender dysphoria in children and adolescents will be available to read about in which cases blockers can be useful, how doctors and therapists should weigh up the advantages and disadvantages and which therapies can still help young people.
